Soft tissue reconstruction of complex infra-inguinal wounds following revisionary vascular surgery

INTRODUCTION

Large, full thickness infra-inguinal wounds following revision revascularization procedures of the lower extremity are a challenging complication for reconstructive surgery. Frequently, these patients present with various comorbidities and after several previous reconstructive attempts and therefore no straightforward soft tissue reconstruction is likely.

METHODS

Patients who presented with large, complex inguinal wounds for soft tissue reconstruction were analyzed retrospectively in terms of flap choice, outcome and complication rates. A focus was set on the reconstructive technique and a subgroup analysis was assessed.

RESULTS

19 patients (11 men, 8 women) who received 19 flaps (17 pedicled, two free flaps) were included in this retrospective study. Average patient age was 73.3 years (range: 53-88 years). 10 fascio-cutaneous flaps (ALT, 52.6%) and 9 muscle flaps (47.4%) were applied. Among muscle flaps, 3 pedicled gracilis flaps, 4 pedicled rectus abdominis flaps and two free latissimus dorsi flaps were used. No flap losses were observed except one case of limited distal flap necrosis (gracilis group). Body Mass Index (BMI) ranged from 19 to 37, mean 26.8. Mean surgery time in all patients was 165.9 minutes (range: 105-373 minutes). Revision surgery due to local wound healing problems averaged 1.6 in all patients. In all cases sufficient soft tissue reconstruction was achieved and bypasses were preserved. Lengths of stay averaged 27.2 (14 to 59 days). Mortality was considerably (10.5%) due to systemic complications (One patient died due to a heart attack 4 weeks postoperatively, another patient died due to an extensive pulmonary embolism two weeks postoperatively).

CONCLUSION

Soft tissue reconstruction of complex inguinal wounds after revision vascular surgery is challenging and wound-healing problems are expectable. In addition to the rectus abdominis flap the pedicled ALT flap is feasible in a broad variety of medium to large wounds. Free flap reconstruction is recommended for very large defects. A structured interdisciplinary approach is required for the management of complex wounds after vascular surgery to prevent and to deal with complications and perioperative morbidity.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with acute and chronic aortic conditions

OBJECTIVES

To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on acute and elective thoracic and abdominal aortic procedures.

METHODS

Forty departments shared their data on acute and elective thoracic and abdominal aortic procedures between January and May 2020 and January and May 2019 in Europe, Asia and the USA. Admission rates as well as delay from onset of symptoms to referral were compared.

RESULTS

No differences in the number of acute thoracic and abdominal aortic procedures were observed between 2020 and the reference period in 2019 [incidence rates ratio (IRR): 0.96, confidence interval (CI) 0.89-1.04; P = 0.39]. Also, no difference in the time interval from acute onset of symptoms to referral was recorded (<12 h 32% vs > 12 h 68% in 2020, < 12 h 34% vs > 12 h 66% in 2019 P = 0.29). Conversely, a decline of 35% in elective procedures was seen (IRR: 0.81, CI 0.76-0.87; P < 0.001) with substantial differences between countries and the most pronounced decline in Italy (-40%, P < 0.001). Interestingly, in Switzerland, an increase in the number of elective cases was observed (+35%, P = 0.02).

CONCLUSIONS

There was no change in the number of acute thoracic and abdominal aortic cases and procedures during the initial wave of the COVID-19 pandemic, whereas the case load of elective operations and procedures decreased significantly. Patients with acute aortic syndromes presented despite COVID-19 and were managed according to current guidelines. Further analysis is required to prove that deferral of elective cases had no impact on premature mortality.

Mortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA)

OBJECTIVES

Acute aortic dissection type A (AADA) is an emergency with excessive mortality if surgery is delayed. Knowledge about independent predictors of mortality on surgically treated AADA patients is scarce. Therefore, this study was conducted to identify pre- and intraoperative risk factors for death.

METHODS

Between July 2006 and June 2010, 2137 surgically treated patients with AADA were enrolled in a multicentre, prospective German Registry for Acute Aortic Dissection type A (GERAADA), presenting perioperative status, operative strategies, postoperative outcomes and AADA-related risk factors for death. Multiple logistic regression analysis was performed to identify the influence of different parameters on 30-day mortality.

RESULTS

Overall 30-day mortality (16.9%) increased with age [adjusted odds ratio (OR) = 1.121] and among patients who were comatose (adjusted OR = 3.501) or those who underwent cardiopulmonary resuscitation (adjusted OR = 3.751; all P < 0.0001). The higher the number of organs that were malperfused, the risk for death was (adjusted OR for one organ = 1.651, two organs = 2.440, three organs or more = 3.393, P < 0.0001). Mortality increased with longer operating times (total, cardiopulmonary bypass, cardiac ischaemia and circulatory arrest; all P < 0.02). Arterial cannulation site for extracorporeal circulation, operative techniques and arch interventions had no significant impact on 30-day mortality (all P > 0.1). No significant risk factors, but relevant increases in mortality, were determined in patients suffering from hemiparesis pre- and postoperatively (each P < 0.01), and in patients experiencing paraparesis after surgery (P < 0.02).

CONCLUSIONS

GERAADA could detect significant disease- and surgery-related risk factors for death in AADA, influencing the outcome of surgically treated AADA patients. Comatose and resuscitated patients have the poorest outcome. Cannulation sites and operative techniques did not seem to affect mortality. Short operative times are associated with better outcomes.

The Impact of Pre-Operative Malperfusion on Outcome in Acute Type A Aortic Dissection: Results From the GERAADA Registry

BACKGROUND

Malperfusion adversely affects outcomes in patients with acute type A aortic dissection, but reliable quantitative data are lacking.

OBJECTIVES

The aim of this study was to analyze the impact of various forms of malperfusion on early outcome.

METHODS

A total of 2,137 consecutive patients enrolled in GERAADA (German Registry for Acute Aortic Dissection Type A) who underwent surgery between 2006 and 2010, of whom 717 (33.6%) had any kind of pre-operative malperfusion, were retrospectively analyzed.

RESULTS

All-cause 30-day mortality was 16.9% and varied substantially according to the number of organ systems affected by malperfusion (none, 12.6%; 1 system, 21.3%; 2 systems, 30.9%; 3 systems, 43.4%; p < 0.001). Pre-operative cerebral malperfusion, comatose state, peripheral malperfusion, visceral malperfusion, involvement of supra-aortic branches, coronary malperfusion, and renal malperfusion were all independent predictors of developing any post-operative malperfusion syndrome. When survival was considered, age, peripheral malperfusion, involvement of supra-aortic branches, coronary malperfusion, spinal malperfusion, a primary entry in the descending aorta, and pre-operative comatose state were independent predictors, again with increasing significance.

CONCLUSIONS

Malperfusion remains a severe clinical condition with strong potential for adverse outcomes in patients undergoing surgery for acute type A aortic dissection. The GERAADA registry suggests that the impact of the number of organs involved and the type of malperfusion on outcome differs substantially. Introducing an appropriate classification system, such as "complicated" and uncomplicated" acute type A aortic dissection, might help predict individual risk as well as select a surgical strategy that may quickly resolve malperfusion.

New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications

OBJECTIVES

To review the incidence, clinical presentation, definite management and 1-year outcome in patients with aorto-oesophageal fistulation (AOF) following thoracic endovascular aortic repair (TEVAR).

METHODS

International multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2011 with a total caseload of 2387 TEVAR procedures (17 centres).

RESULTS

Thirty-six patients with a median age of 69 years (IQR 56-75), 25% females and 9 patients (19%) following previous aortic surgery were identified. The incidence of AOF in the entire cohort after TEVAR in the study period was 1.5%. The primary underlying aortic pathology for TEVAR was atherosclerotic aneurysm formation in 53% of patients and the median time to development of AOF was 90 days (IQR 30-150). Leading clinical symptoms were fever of unknown origin in 29 (81%), haematemesis in 19 (53%) and shock in 8 (22%) patients. Diagnosis could be confirmed via computed tomography in 92% of the cases with the leading sign of a new mediastinal mass in 28 (78%) patients. A conservative approach resulted in a 100% 1-year mortality, and 1-year survival for an oesophageal stenting-only approach was 17%. Survival after isolated oesophagectomy was 43%. The highest 1-year survival rate (46%) could be achieved via an aggressive treatment including radical oesophagectomy and aortic replacement [relative risk increase 1.73 95% confidence interval (CI) 1.03-2.92]. The survival advantage of this aggressive treatment modality could be confirmed in bootstrap analysis (95% CI 1.11-3.33).

CONCLUSIONS

The development of AOF is a rare but lethal complication after TEVAR, being associated with the need for emergency TEVAR as well as mediastinal haematoma formation. The only durable and successful approach to cure the disease is radical oesophagectomy and extensive aortic reconstruction. These findings may serve as a decision-making tool for physicians treating these complex patients.

Strategies for endovascular aortic repair in aortobronchial and aortoesophageal fistulas

OBJECTIVE

To report our experience of thoracic endovascular aortic repair (TEVAR) for acute bleeding originating from the thoracic aorta in patients with aortobronchial fistula (ABF) or aortoesophageal fistula (AEF).

PATIENTS AND METHODS

A total of nine patients (three woman) were treated from September 1995 to March 2012 by TEVAR for ABF (n = 5) and AEF (n = 4). The implants (N = 14) were introduced with fluoroscopic guidance via the aorta (n = 1), the iliac (n = 2), or femoral (n = 11) artery, respectively.

RESULTS

All aortic lesions could be sealed successfully. Perioperative morbidity was 0% in the ABF group and 50% (2 of 4) in the AEF group and no procedure-related morbidity was noted except one patient who received aortofemoral reconstruction because of iliac occlusive disease. After an overall mean follow-up of 56 months, three patients of the ABF group are alive and well and two patients died of nonrelated cause. Of the AEF group, one patient is alive after 22 months, and one died from metastasized esophageal cancer after 7 months.

CONCLUSION

TEVAR is a safe and reliable procedure in the management of ABF. For AEF, TEVAR provides a successful first-line treatment to seal the fistula and control bleeding. However, prognosis is limited by the esophageal lesion and by ongoing mediastinitis/sepsis.

Endovascular treatment of symptomatic true-lumen collapse of the downstream aorta after open surgery for acute aortic dissection type A

AIM

The aim of the present study was to evaluate the outcome of endovascular treatment of true-lumen collapse (TLC) of the downstream aorta after open surgery for acute aortic dissection type A (AADA).

METHODS

Retrospective, observational study with follow-up of 16 ± 7.6 months. From April 2010 to January 2012, 89 AADA-patients underwent aortic surgery. Out of these, computed tomography revealed a TLC of the downstream aorta in 13 patients (14.6%). They all received additional thoracic endovascular aortic repair (TEVAR) in consequence of malperfusion syndromes.

RESULTS

In all 13 TLC-patients, dissection after AADA-surgery extended from the aortic arch to the abdominal aorta and malperfusion syndromes occurred. Remodeling of the true-lumen was achieved by TEVAR with complemental stent disposal in abdominal and iliac arteries in all cases. One patient died on the third postoperative day due to intracerebral hemorrhage. Another patient, who presented under severe cardiogenic shock died despite AADA-surgery and TEVAR-treatment. Thirty-day mortality was 15.4% in TLC-patients (N = 2/13). In the follow-up period, 3 patients required additional aortic stents after the emergency TEVAR procedures. After 20 weeks, a third patient died secondary to malperfusion due to false-lumen recanalization. Therefore, late mortality was 23.1%.

CONCLUSION

After proximal aortic repair for AADA, early postoperative computed tomography should be demanded in all patients to exclude a TLC of the descending aorta. Mortality is still substantial in these patients despite instant TEVAR application. Thus, in case of TLC and malperfusion syndrome of the downstream aorta, TEVAR should be performed early to alleviate or even prevent ischemic injury.

Acute aortic dissection type A

Background

Acute aortic dissection type A (AADA) is a life-threatening vascular emergency. Clinical presentation ranges from pain related to the acute event, collapse due to aortic rupture or pericardial tamponade, or manifestations of organ or limb ischaemia. The purpose of this review was to clarify important clinical issues of AADA management, with a focus on diagnostic and therapeutic challenges.

Methods

Based on a MEDLINE search the latest literature on this topic was reviewed. Results from the German Registry for Acute Aortic Dissection Type A (GERAADA) are also described.

Results

Currently, the perioperative mortality rate of AADA is below 20 per cent, the rate of definitive postoperative neurological impairment approaches 12 per cent and the long-term prognosis after surviving the acute phase of the disease is good. Many pathology- and therapy-associated factors influence the outcome of AADA, including prompt diagnosis with computed tomography and better cerebral protection strategies during aortic arch reconstruction. Endovascular technologies are emerging that may lead to less invasive treatment options.

Conclusion

AADA is an emergency that can present with a wide variety of clinical scenarios. Advances in the surgical management of this complex disease are improving outcomes.

How to do it: direct true lumen cannulation technique of the ascending aorta in acute aortic dissection type A

In acute aortic dissection type A (AADA), direct true lumen cannulation (DTLC) of the ascending aorta is a fast and safe cannulation site providing antegrade perfusion of the supraaortic and visceral vessels. An Overholt clamp is passed around the ascending aorta to place a Mersilene tape for later securing of the arterial cannula. After draining venous blood into the cardiopulmonary bypass system (CPB), the ascending aorta is transected and the aortic lumen inspected. The true lumen is identified and an arterial cannula inserted directly. Finally, the cannula is secured with the previously placed tape and CPB is initiated. DTLC can be used as arterial cannulation standard technique in operations for AADA.

Cerebral Protection During Surgery for Acute Aortic Dissection Type A

Background—

Cerebral protection during surgery for acute aortic dissection type A relies on hypothermic circulatory arrest, either alone or in conjunction with cerebral perfusion.

Methods and Results—

The perioperative and intraoperative conditions of 1558 patients submitted from 44 cardiac surgery centers in German-speaking countries were analyzed. Among patients with acute aortic dissection type A, 355 (22.8%) underwent surgery with hypothermic circulatory arrest alone. In 1115 patients (71.6%), cerebral perfusion was used: Unilateral antegrade cerebral perfusion (ACP) in 628 (40.3%), bilateral ACP in 453 (29.1%), and retrograde perfusion in 34 patients (2.2%). For 88 patients with acute aortic dissection type A (5.6%), no circulatory arrest and arch intervention were reported (cardiopulmonary bypass–only group). End points of the study were 30-day mortality (15.9% overall) and mortality-corrected permanent neurological dysfunction (10.5% overall). The respective values for the cardiopulmonary bypass–only group were 11.4% and 9.1%. Hypothermic circulatory arrest alone resulted in a 30-day mortality rate of 19.4% and a mortality-corrected permanent neurological dysfunction rate of 11.5%, whereas the rates were 13.9% and 10.0%, respectively, for unilateral ACP and 15.9% and 11.0%, respectively, for bilateral ACP. In contrast with the ACP groups, there was a profound increase in mortality when systemic circulatory arrest times exceeded 30 minutes in the hypothermic circulatory arrest group ( P <0.001). Mortality-corrected permanent neurological dysfunction correlated significantly with perfusion pressure in the ACP groups.

Conclusions—

This study reflects current surgical practice for acute aortic dissection type A in Central Europe. For arrest times less than 30 minutes, hypothermic circulatory arrest and ACP lead to similar results. For longer arrest periods, ACP with sufficient pressure is advisable. Outcomes with unilateral and bilateral ACP were equivalent.

Long-term patency of open revascularization for visceral artery pathologies

OBJECTIVE

Aim of the study was to evaluate the long-term patency of bypass grafts used to treat occlusive and aneurysmal disease of the visceral arteries.

METHODS

A retrospective analysis of our vascular surgery database identified 30 patients (11 men, mean age 59 ± 14 years) who underwent 32 operations for visceral artery pathology between January 1995 and December 2009. Acute mesenteric ischemia (aMI) was present in 10, chronic mesenteric ischemia (cMI) in 14 and visceral artery aneurysm (VAn) in 7 cases. The primary endpoint of this study was vessel patency, secondary endpoints were survival and freedom from reintervention.

RESULTS

A total of 46 vessels were revascularized (26 bypass grafts) and additional revascularization procedures (thromboembolectomy, patch plasty, transposition) were performed in 21 cases. In the perioperative period, 6 deaths (5 aMI, 1 cMI) occurred, resulting in a mortality rate of 50 % for aMI and 7 % for cMI. At long-term follow-up (55 months), 22 patients (100 % follow-up) were interviewed and 21 were scheduled for clinical and imaging examinations. Four vessel (3 grafts) occlusions were found in these patients.

CONCLUSION

We were able to show that bypass grafting for a visceral artery pathology, although associated with an increased perioperative mortality, is a successful and durable procedure.

Symptomatic atherosclerotic occlusive disease of all supra-aortic arch vessels treated with total aortic arch rerouting

We present an uncommon case of symptomatic atherosclerotic occlusive disease of all supra-aortic arch vessels and its surgical treatment by total aortic arch rerouting after endarteriectomy of all target vessels.